College Admissions Form

Visiting Students Audition Rotation Program Application
Thank you for your interest in the Visiting Students Audition Rotations Program with the Mobile Infirmary Internal Medicine Residency Program! This program is an opportunity for fourth-year medical students to participate in an array of elective clinical rotations that foster the growth of medical knowledge through direct patient care experiences.

*Participation in a visiting student audition rotation does not guarantee an invitation for a residency program interview. Invitations to interview are provided at the discretion of Mobile Internal Medicine Residency program.
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Social Security Number *
Gender

MaleFemaleNon-BinaryPrefer not to Answer
Of which country are you a citizen?*
Phone*
E-mail Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Relationship*
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Do you speak any languages other than English?*

YesNo
Please list them

School/Rotation Information
Undergraduate College*
Graduation Date*

MonthDayYear
Date
Does your Medical School have an Affiliation Agreement with Mobile Infirmary Medical Center?*

YesNoUnsure
If you answered No or Unsure, please contact your Medical School to confirm. If there is no current affiliation agreement, your medical school representative will need to email LaTasha Williams, C-TAGME at latasha.williams@infirmaryhealth.org to initiate an agreement

Letters of Recommendation should be emailed to latasha.williams@infirmaryhealth.org
Medical School*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Medical School Email*
example@example.com
Anticipated Graduation Date*
Medical School Placement Coordinator*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Upload Required Documents: Personal Statement, Medical School transcript, Proof of Health Insurance, ACLS, BLS, USMLE/COMLEX Score Report, copy of certificate of Malpractice/Medical Liability Insurance Coverage, CV, Headshot, Copy of Driver's License or Government Issued Identification, Copy of current Flu shot record, copy of Immunization Records, Copy of TB Test-Completed in the last year, Proof of results of a negative 10-panel drug screen, Proof of Background Screen*

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Visiting Students Audition Rotation Program Application